Post Acute Providers Going All Home Care 100, February ... · Targeting Criteria: ... • Northwell Health (Long Island, New York) ... Post Acute Providers Going All. Home Care 100,

Home Care 100, February 2017Post Acute Providers Going All-In On Risk

Jade Gong (Moderator)Principal JadeGong & Associates [email protected]

Kelly Hopkins President & CEOTrinity Health [email protected]

Lynn JonesPresident & CEOChristiana Care Health [email protected]

Home Care 100, February 2017

If you are not taking risk, you are at risk.Anonymous


Three Major Types of Risk

Source: HFMA The Future of Value: Managing Populations, Contracts, and Risk, April 2013

Transition Risk“Feet in both worlds”

Insurance RiskCapitated or episodic payment structures for a set

amount of services or lives

Performance RiskCreating value through best-in-class quality

Home Care 100, February 2017Trinity Health

4

Home Care & Hospice Locations Serving 116 Counties47 Continuing Care

Facilities59PACE CenterLocations17

Hospitals* in 20 Regional Health Ministries**92 Mission Health

Ministries4Employed Physicians 5,300

Affiliated Physicians23,900National Health

Ministries***3

Our 22-State Diversified Network

*Owned, managed or in JOAs or JVs.

**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.

***Includes multiple locations for Trinity Home Health Services, Trinity Senior Living Communities and PACE facilities.

Home Care 100, February 2017Trinity Health PACE National Footprint –13 Programs in 9 states

5

1

CA

AZ

NV

OR

MT

MN

NE

SD

ND

ID

WY

OK

KSCO

UT

TX

NM SC

FL

GAAL 1MS

LA

AR

MO

IA

VA

TN

IN 1

KY

IL

M 1I

WV

WA

OH

PA 3

NY 2

VT

ME

CT

NJ 2

D.C.

WI NHMA

RI

DE 1MD

NC 1

AK

HI

PACE State

Non-PACE State

TH PACE State


What is PACE?• The Program of All-inclusive Care for the Elderly (PACE) is designed to provide the entire continuum of

care and services to frail seniors, helping them to maintain their independence in their home and

community for as long as possible


55 years of age or older

Live in a PACE service area

Be certified as eligible to receive nursing home level of care (as determined by the State)

Be able to live safely in the community at point of enrollment

Who Do We Serve?

2015 PACE Innovation Act will allow CMS to develop pilot projects for the PACE model to be used as a platform for innovation to serve more seniors as well as younger individuals in need of integrated care and services


• PACE Services– Primary Care– Episodic Care

• Inpatient Hospital• Skilled Nursing

– Specialist Care– Social Services– Adult Day– Recreation– PT/OT– In home services– Dietary services (dietician

assessment/ recommendations, hot meals in center, supplements)

– Transportation– Anything else the IDT

determines as necessary

What Does PACE Provide For Seniors…..Exactly?


Specialty Care

Medication Supplies

DME

Transportation

Meals

Personal Care

Subacute Care

Hospital Care

• The Interdisciplinary Team (IDT), with the participant and caregiver, develop an individualized plan of care (POC) based on data from the IDT assessment and participant and family goals

• The POC is updated at six months and on an as needed basis

• Most care plans include care at the PACE Center and in the home

• Most participants attend the PACE Center 2 – 3 times each week

• Participants must agree to receive all services and medications through the PACE provider network (exceptions for emergency and urgent care)

• Some PACE Organizations allow continued visits with prior PCP

Interdisciplinary TeamA LIFE Plan of Care


IDT Balancing Act

• Wants and needs of participant and family

• Individualized care plans• Creativity of individual IDT

members

• Appropriate utilization of necessary services

• Uniform tools that guide decision making

• Stewardship of resources

10


• Payment features are unique compared to other health care payment models

• Capitated payment system (per member per month)

• Combines funding from multiple sources to meet all participant needs Medicare Part A & B Medicare Part D Medicaid Private Pay (less common)

• Program is completely at risk

Integrated Capitated Reimbursement

Pooled Capitation (PMPM)

Medicare Part D

Medicare Medicaid

Private Pay


Balancing Services and Dollars19

Use Dollars Sparingly• Hospital• Emergency Room• Nursing Home

Use Dollars Generously• PACE Team• Home Health• Day Center


Key Points

Traditional Model:Fragmentation

PACE Model:Integration

Care• Multiple providers

• Discontinuity across sites

Financing• Multiple payors

• Institutional bias

• Restrictions

Care• Outpatient care

• Acute care

• Long-term care

Financing• All-inclusive

• Full risk

• No restrictions

Home Care 100, February 2017Dashboard – April

14

12 month rolling: May 2016 - April 2017 Pres

sure

Inju

ry p

er 1

000

part

icip

ant

days

UTI

per

100

0 pa

rtic

ipan

t day

s

maj

or in

jury

falls

per

100

m

embe

r m

onth

s

% im

mun

ized

for P

N

% im

mun

ized

for f

lu

ER v

isits

per

mem

ber

per

annu

m

Acut

e IP

adm

issi

ons

per

mem

ber

per a

nnum

Acut

e IP

adm

issi

ons

per 1

,000

m

embe

rs

Read

mis

sion

s

SNF

days

per

mem

ber

per

mon

th

% P

artic

ipan

ts i

n H

ome/

Com

mun

ity

Wha

t is

your

reco

mm

enda

tion

of P

ACE

to o

ther

s? -

%Ex

celle

nt

Empl

yee

Enga

gem

ent I

ndic

ator

sc

ore

Trinity Health System PACE Organizations Average 5.42 0.82 0.46 91% 89% 0.65 0.65 645 17% 0.45 91.4% 63% 4.19 1.82Threshold (Median) 4.48 0.78 0.5 80% 80% 0.57 0.65 643 18% 0.53 96% 60% 4.08 1.5Target (Top Quartile) 2.59 0.75 0.34 90% 86% 0.38 0.46 563 14% 0.36 98.3% 76% 4.1 2.35

Lower is better

Lower is better

Lower is better Higher is better Higher is better Lower is better Lower is better Lower is better Lower is better Lower is better

Higher is better Higher is better

Higher is better Higher is better

Clinical Scorecard

Financial Summary

Actual Budget Variance % Variance

Operating Revenue (000s) $229,196 $231,516 ($2,320) (1.00)%Operating Expense (000s) $217,691 $222,950 $5,259 2.36 %Operating Margin (000s) $11,505 $8,566 $2,939 34.31 %Operating Margin % 5.02 % 3.70 % 1.32 % 35.67 %Operating Cash Flow (000s) $15,447 $12,683 $2,764 21.79 %Operating Cash Flow 6.74 % 5.48 % 1.26 % 23.03 %Member Months 30,005 31,075 (1,070) (3.44)%Operating Revenue PMPM $7,639 $7,450 $188 2.53 %Operating Expense PMPM $7,255 $7,175 ($81) (1.12)%

Total System PACE - All PACE programs and TH PACE


Post Acute Providers Going All-In On RiskPOST ACUTE LINK

Lynn C. JonesPresident, Home Health & Community Services

SVP, Post Acute Care Services


• Major teaching hospital with four campuses. Largest teaching affiliate hospital for Sidney Kimmel Medical College at Thomas Jefferson University, training more than 280 residents annually.

• Delaware’s largest private employer. (more than 11,000 employees)

• Accountable Care Organization (ACO). Statewide partnership with hospitals, health centers and community physicians in Medicare Shared Savings Program.

• Net operating revenue of $1.8 billion.

o Home Health Care visits: 312,537o 22nd in U.S. Admissions: 53,259o 28th in U.S. Surgeries: 39,102o 21st in U.S. ED Visits: 197,340o 31st in U.S. Births: 6,545


• Targeting Criteria: IAH-Qualifying criteria identify 6% of the FFS population with high cost and high mortality

• Intervention: Home based primary care using mobile interdisciplinary teams with local flexibility in composition, meeting patients “where they are”

• Payment Model: Aligns incentives , using “Shared Savings with Discipline”, covering all A&B spending tied to Quality Metrics; with suspension for non-performance

Independence at Home Demonstration


• Two or more chronic conditions.

• Need for assistance with two or more functional dependencies.

• Non-elective hospital admissions within the last 12 months.

• Received acute or sub-acute rehabilitation services in the last 12 months in SNF, IRF, or Home Health.

• Traditional Medicare only

HCC score for average Medicare beneficiary is 1.0. PACE score is 2.5 and IAH is 3.6.

IAH Qualifying Criteria


IAH “Learning Collaborative”• Boston Medical Center (Boston, Massachusetts)• Christiana Care Health System (Wilmington, Delaware)• Cleveland Clinic Home Care Services (Independence, Ohio)• Comprehensive Geriatric Medicine, P.C. d/b/a Doctors on Call

(Brooklyn, New York)• Doctors Making Housecalls, LLC (Durham, North Carolina)• Housecall Providers, Inc. (Portland, Oregon)• MD2U (Louisville, Kentucky)• National Housecall Practioners Group (Austin, Texas)• Northwell Health (Long Island, New York)• Visiting Physicians Association (Wisconsin, Michigan, Texas, Florida)• Mid-Atlantic Consortium (Penn, VCU, WHC)


IAH Quality Metrics• Follow-up within 48 hours after hospital admission, hospital

discharge, and emergency department visits.

• In-home medication reconciliation within 48 hours of hospital discharge and emergency department visits.

• All-cause hospital readmissions within 30 days.

• Annual documentation of patient preferences.

• Hospital admission rate for ambulatory care sensitive conditions.

• Emergency department visit rate for ambulatory care sensitive conditions.


IAH Gain Share Model• CMS sets a “spending target”

• If savings is achieved; • First, CMS keeps an amount equal to 5% of the

spending target (Then, at least 20% of the remaining savings)

• Providers may receive 80% - 50% of remaining savings based on quality indicators

• Key challenge is delay in receiving claims data (2 year delay)


IAH Demo Year 1 and 2 Results

$11.7 awarded in shared savings• CMS retained 54% of savings• Top savings program saved 32%;

Savings among the 9/17 who received shared savings averaged 17%

All programs improved on 3 out of 6 quality measures• Four programs met all 6 quality

measures

$5.1 awarded in shared savings• CMS retained 35% of savings• Top savings program saved 26%;

Savings among the 7/15 who received shared savings averaged 14%

All programs improved quality from the first performance year in at least two of the six quality measures • Four programs met all 6 quality

measures

Year 1 Year 2


CCHS Home Visit Program (includes IAH)Staffing: • 5 MD (3FTE)• 6 NP/PAs (4.6 FTE)• 2 RNs• 2 RN Case Managers• 3 Social Workers• 4 MAs• 1 Office Manager • 1 Program Manager


CCHS Home Visit Program (includes IAH)

A Few Key Metrics:• Completing year 5 (may extend 2 more years)• 625 HV patients (290 are IAH)• 80 on “waiting list” • 12 month “LOS”• ED Visits (25%)• Hospitalizations (15%)• Patient engagement ↑• ($800k) loss per year on operations• No gain share years 1 & 2


CCHS Home Visit ProgramKey Learnings:• Social Worker as key role• VNA “embedded” Nurses• Risk Stratification = Customized visit patterns• Management of “SNF days”• “Transition team”• Need to add efficiency, revise model and reduce

loss


CCHS Home Visit Program“Fit” into system’s Continuum of Care• Unique class of patients• Unique level/intensity of care = IAH• “Typical ACO case management” not effective for these

patients• Continue to learn; leverage technology; work at “top of

license”; get better at social determinates, end of life care, and efficiency

Home Care 100, February 2017Post Acute Providers Going All-In On Risk

Jade Gong (Moderator)Principal JadeGong & Associates [email protected]

Kelly Hopkins President & CEOTrinity Health [email protected]

Lynn JonesPresident & CEOChristiana Care Health [email protected]

Documents

Post Acute Providers Going All Home Care 100, February ... · Targeting Criteria: ... • Northwell Health (Long Island, New York) ... Post Acute Providers Going All. Home Care 100,